Case 207: Manual of CTO PCI - Treat the donor vessel first!

A patient with ischemic cardiomyopathy was referred for PCI of a distal RCA CTO. Antegrade wire escalation was tried first resulting in crossing into an acute marginal branch with a Hornet 14 wire. We were unable to advance the microcatheter into the acute marginal despite using a Guidezilla and a 1.0 mm Sapphire Pro balloon. After multiple passes with a 0.9 mm laser we were able to advance the microcatheter into the acute marginal branch and changed the Hornet for a workhorse wire. We used a dual lumen microcatheter and a Gaia 2nd wire but it kept on entering a more distal acute marginal branch. We decided to switch to retrograde crossing.
The patient developed hypotension and ST segment changes upon left main engagement and IVUS showed severe left main disease. We tried to insert an Impella CP device but were unable to advance it past the distal aortic bifurcation. We used the long Impella sheath and were then able to advance the Impella into the left ventricle. We stented the left main using the provisional stenting technique into the LAD. We then crossed a septal did reverse CART and successfully stented the RCA with an excellent final result.

[@shangz0216]

Thanks for the excellent case presentation.

[@krishnasagar2342]

Great case Professor....how do you manage with such low volumes of contrast? Do you suggest adequate dilution of contrast with saline?

[@manosbrilakis]

250 ml is not a low volume of contrast! Using intravascular imaging and being selective about when to inject can help.

[@louischea845]

fantastic case sir